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Terms in this set (81)

-nursing responsibility to educate, assist, counsel, and prevent complications
-comprehensive approach to care can help the patient successfully adjust to home, work, and society
risk for injury r/r new environment
-orient to the patient to the environment
-use therapeutic touch
-avoid loud sounds that may startle the patient
-use protective devices, such as side rails and canes
-alter surroundings to afford safety (clear passageways, nonslip rugs, etc)
AHN 610
1. when speaking , use a normal tone of voice
2. alert client when approaching
3. orient client to environment
4. use focal point and provide further orientation from focal point
5. allow client to touch objects in room
6. use clock placement of foods on meal tray to orient client
7. promote independence as much as possible
8. provide radios, televisions, and clocks that give the time orally, or provide a Braille watch
9. when ambulating, allow the client to grasp the nurse's arm at the elbow; keep your arm close to the body so that the client can detect the direction of movement
10. instruct the client to remain one step behind the nurse when ambulating
11. instruct the client in the use of the can used for the blind client, which is differentiated from other canes by its straight shape and white color with red tip
12. instruct the client that the cane is held in the dominant hand several inches off the floor
13. instruct the client that the cane sweeps the ground where the client's foot will be placed next to determine the presence of obstacles
NCLEX 767